TCS Daily


Libyan AIDS Trial Exposes Wider Truths

By Roger Bate - December 21, 2006 12:00 AM

Moammar Gaddafi's regime has condemned to death five Bulgarian nurses and a Palestinian doctor for "deliberately" infecting Libyan children with HIV in a hospital in Benghazi. The media have reported confessions made under torture and systematic sexual abuse of the nurses by prison guards. The media's scrutiny of this sorry and tragic episode has called into question Gaddafi's credibility, weak government and corrupt judiciary.

But the real AIDS story is that Libya is not unique. Patients across the developing world are being infected with HIV in the same way that these unfortunate Libyan children were -- not through sexual relations, but through poor clinical and hygiene practice. Yet while this fact is known by many health experts, both in the West and in poor countries, the media and some donor agencies, including the UN, are concentrating on sexual transmission.

When it was discovered eight years ago that 426 children had been infected with HIV (of whom 53 have since died), a Libyan magazine suggested that poor clinical hygiene was to blame. Indeed, evidence presented at the appeal court by experts from Oxford University showed that the HIV and hepatitis C the children contracted had been prevalent long before the Bulgarian nurses came along.

Indeed, the tragedy in Libya is likely being repeated routinely in any clinic suffering from the euphemistic "lack of capacity." Simply put, needles are routinely re-used and unscreened blood is transfused.

In many developing countries injections and transfusions are both administered far more frequently than is common in western medical practice. The World Health Organization estimates that 10% of total HIV infections are caused by clinical practice -- so-called iatrogenic infections. Other evidence suggests the real rate is much higher, especially in the poorest locations. As the multiple authors in the prestigious British Journal of Obstetrics and Gynaecology highlighted in a 2003 paper (http://www.cirp.org/library/disease/HIV/brody1/):

"There is mounting evidence that rapid HIV transmission is fuelled by parenteral exposures in health care settings, especially medical injections but also including transfusion of untested blood and others.....The common belief that 90% of HIV transmission in Africa is driven by heterosexual exposure is no longer tenable."

The BBC, in a rare report on the issue, reviewed the above paper and other research and said:

"Some researchers believe as many as 40% of HIV infections in African adults are linked to injections. United Nations agencies have rejected this theory, saying most cases are linked to unsafe sex. Officials have also warned that the theory could damage campaigns to get people in Africa to use condoms to protect themselves from the disease."

Mark Dybul, the U.S. Global AIDS coordinator, has explained that sexual transmission of HIV was probably stabilizing in sub-Saharan Africa thanks to education programs. However, he also rightly points out that "the new task is to stop infections through blood transfusion, which is difficult for poor countries saddled with both decrepit medical facilities and HIV infection rates reaching as high as 40 percent in some areas."

So the real question is not whether the causes of HIV are just sexual - its obvious they're not - but how do proud nations admit that their own unhygienic clinics and outdated practices are often the cause?

One way forward is simply to tell the truth. A doctor working in India we spoke with (who wished to stay anonymous) explained the case of a boy so severely anemic with malaria that his death was imminent without a transfusion. The doctor had no access to testing facilities, or supplies of fresh, clean blood. His only option would be to hook up a family member directly for a transfusion or, in an extreme case, resort to buying blood from touts outside the hospital. In Uganda, brave efforts were made to regularize its blood bank service and to introduce volunteer blood donations after infrastructure and systems had broken down during and after the the Idi Amin years. When blood taken (initially for a fee) was first tested, 25% of samples were infected with HIV, many also had Hepatitis A & C, and other sexually transmitted diseases, such as gonorrhea. It is likely to be the same in any poor country. As the Indian doctor said of his practice, "I have the choice between letting the poor little fellow die tomorrow, or running the risk that he may eventually die of AIDS." Unfortunately this truth often remains hidden since doctors such as this one are afraid of being so candid publicly, for fear of losing their jobs.

Gaddafi's perverse flair in shifting the blame to "malign" foreigners has caused shock and outrage worldwide, and we fervently hope that these hapless health workers do not face a firing squad. Yet, his actions may have done some good in bringing the causes of HIV transmission into the open. It may be that western assumptions and expectations contribute to African leaders' reluctance to point the finger of blame at other African regimes or their own government's failings; but it is surely possible for NGOs, international donors, academics to help out without being offensive. Meaning well is not good enough if the actual results are poor or perverse.

As with most afflictions keeping populations sick and poor in the world, there is a well-proven solution. In this case it is not technically difficult nor even very expensive, but it is hampered by a lack of frankness and bravery. Education programs seem to be popular with donors, so we recommend one aimed at reducing patient demand for injections (90% of doctor visits in Africa feature an injection) and replacing it with a demand for sterile, single-use vials and hypodermics. Alongside efforts to guarantee safe blood these programs could eliminate iatrogenic transmission.

And while the Washington Post, for one, has done a good job of exposing the awful Libyan story, the bigger question is, Why have hospitals and clinics all over the developing world been allowed, and unwittingly encouraged, to transmit deadly disease for so long?

Lorraine Mooney is a medical demographer with Africa Fighting Malaria, Roger Bate a Resident Fellow of the American Enterprise Institute.


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4 Comments

Got to love that UN
Once again, the UN to the rescue.

hindsight is a wonderful thing Lorraine
I'm sure that if you were running the place there would be no mistakes. Just as a matter of interest can you point to any pieces by you on this subject from say two years ago? Can you point to any Us programs in that have made a point about this in the past. It's easy to bash the UN while ignoring your own mistakes, but then again that is a preoccupation of the rednecks in the US.

Great article...
This points up the fundamental problem of raw poverty in a global economy where only primative elements of the technology of modern medicine are available. Some physicians actually do more harm than good when they don't have the resources to do their work properly.

While we wring our hands about the possible risk of global warming (sometime in the future) due to industrial development any slowing of economic expansion, especially in places where direct labor workers earn $1-$2 a day, directly threatens the lives of such populations today.

We need to accelerate the economic development of these nations and solve any such energy or logistical challenges as we go along.

Governments have a terrible record in this regard. The World Bank has not been effective. NGO's waste a lot of money. Only corporations create wealth and transfer technologies into the workforce allowing those players to get into the global market themselves doing some of the same things we go there to have them do for us better, faster and cheaper than we might do here. If we can convert their cheap labor into dollars then they might quickly learn how to turn their own labor into dollars and pull themselves up by the boot-straps (actually the sneaker laces and flip flops). If an operation does not make money, then it cannot sustain itself and it is not worth doing in the long run. Capitalism trumps charity. Sustainable wealth creation trumps patronizing consumption of the great wealth of people like Warren Buffett. (His $30 billion would be better put to use funding and underwriting modern banking systems so that such nations could lend themselves their own industrial strength working capital the way the Japanese and the Korean banks did, as two good examples.)

The Communist Chinese industrialists are already starting to develop grass roots manufacturing opportunites in Africa. Because their own labor rates are already climbing and their companies understand how to create wealth by converting cheap labor into exports.

Our decades of holier-than-thou policies to encourage democracy before we will take a nation seriously and to simply shake our heads regarding the corruption that we have created by throwing money at poor people (with our Christian sense of charity at a distance) have not resulted in strong governments or economic expansion.

What is wrong with our American companies? Are we so afraid that our precious manufacturing jobs are going overseas that we are missing the opportunity to make money and help people help themselves? Well, the Chinese are not afraid. And they are going to kick our butts in the global marketplace if we don't get our heads out of (down) there. And start taking direct labor tasks more seriously. We won't even cut our own lawns anymore. Workers travel a thousand miles from Mexico to make careers out of trimming the trees in our yards!

Rednecks
We "rednecks in the US" tend to trust elected government more than despots. For some crazy reason, we are deeply offended by tyranny.

There is absolutely no accountability at the UN, as has been shown lavishly by the UN's history of abuse, bribes, kickbacks, and other nauseating things--unless you count the wrist slaps usually given to the perpetrators.

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